Provider Demographics
NPI:1740358886
Name:DOUGAL, MARY A (MD)
Entity type:Individual
Prefix:
First Name:MARY
Middle Name:A
Last Name:DOUGAL
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7421 N MILWAUKEE AVE
Mailing Address - Street 2:
Mailing Address - City:NILES
Mailing Address - State:IL
Mailing Address - Zip Code:60714-3707
Mailing Address - Country:US
Mailing Address - Phone:773-993-0279
Mailing Address - Fax:
Practice Address - Street 1:7421 N MILWAUKEE AVE
Practice Address - Street 2:
Practice Address - City:NILES
Practice Address - State:IL
Practice Address - Zip Code:60714-3707
Practice Address - Country:US
Practice Address - Phone:773-775-0811
Practice Address - Fax:773-819-7013
Is Sole Proprietor?:No
Enumeration Date:2006-11-30
Last Update Date:2023-04-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036059569207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmology
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036059569Medicaid
IL16202167OtherBCBS NUMBER
IL58652Medicare ID - Type UnspecifiedMEDICARE RAILROAD
ILP07286Medicare PIN